CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2011 ending 12/31/2011 Date of Report:02/15/2012 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1054 4248.000000 157147.0000 36.9932
Subtotal (Total Children Is Unduplicated) 1054 4248.000000 157147.0000 36.9932
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 10.000000 750.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 31 32.000000 1776.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 38 21.000000 1575.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 1.000000 75.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 52 34.000000 2550.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 166 145.000000 8047.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 7.500000 562.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 90 90.000000 16361.0000 181.7889
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 22 22.000000 2310.0000 105.0000
Subtotal (Total Children Is Unduplicated) 214 370.500000 34607.0000 93.4062
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Total 4618.500000 191754.0000 41.5187
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Number of Children (Unduplicated) With at Least One Service 1054
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Center 04
Flag Claims Units Chgs Paid
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R 1 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1968 2289.250000 86193.2500 0.0000
P 2005 2086.750000 87851.7500 82521.1500
D 23 26.000000 999.5000 148.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
184 215.750000 16681.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4181 4618.500000 191754.0000 82669.1500